Subspecialization in Orthopaedics: Is There Really Too Much?

Starr, Adam MD; Sarmiento, Augusto MD

Journal of Bone & Joint Surgery - American Volume:
Letters to The Editor
Author Information

Corresponding author (letter): Adam Starr, MD, Department of Orthopaedic Surgery, University of Texas Southwestern, Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8883, adam.starr@utsouthwestern.edu

Corresponding author (reply): Augusto Sarmiento, MD, Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, 1150 Campo San Avenue, Suite 301, Coral Gables, FL 33146, asarm@bellsouth.net

To The Editor:

In his Editorial in the Orthopaedic Forum, Subspecialization in Orthopaedics. Has It Been All for the Better? (2003;85:369-73), Dr. Sarmiento grumbles that there are too many orthopaedic subspecialty journals and that too many residents seek fellowship training. He complains about the increasing number of orthopaedic specialty societies and states: No longer are these societies built around broad bodies of knowledge, but, rather, they are limited to smaller and smaller areas of interest.

Increasing subspecialization is seen in every field of science. Not only are there journals devoted to cell biology, there are journals devoted to cell science, cellular biochemistry, and cellular physiology. There is a journal entitled Gene and others entitled Gene Function and Disease, Gene Therapy, Gene Therapy Weekly, Genes and Development, Genes and Immunity, Gene Chromosomes and Cancer, Genes to Cells, Genetic Epidemiology, Genetic Testing, etc., etc.

Should we halt publication of these extraneous journals? Dr. Sarmiento notes: It is unfortunate that the proliferation of subspecialty journals has reached a degree that has probably done some harm. Does he sincerely believe this explosion in information has been detrimental to people working in the health sciences? Is research increasing because scientists are focusing on smaller and smaller areas of interest?

I don't think so. My guess is that there is simply more to know than in the past. Smaller areas of interest are yielding greater amounts of information. Who could have guessed in 1950 that in 2003 there would be more than 100 journals devoted to the study of genetics? Whereas Galen's knowledge of the causes of infection might occupy a few pages in an ancient medical text, today we have entire books devoted to infection—viral, retroviral, slow-viral, prion-related, bacterial, protozoal, and fungal—and a host of journals that publish articles dealing with infection. Knowledge about musculoskeletal disease has also increased. We understand more than our predecessors did, and there is simply no way to compress that new knowledge into a few easily digestible journals.

Paré's surgical text was a breakthrough in its day, but I would not want to limit myself to what Paré knew about fracture care. State-of-the-art knowledge of spine care, pediatric orthopaedics, hand surgery, sports medicine, and mineral metabolism research cannot be shoe-horned into an already crowded Journal of Bone and Joint Surgery .

I do not think that there are too many journals. If there is room in the world for a journal devoted to agricultural and environmental ethics, surely there is room for a Journal of Orthopaedic Trauma .

Dr. Sarmiento also has criticism for orthopaedic subspecialty societies. He notes: The Orthopaedic Trauma Association devotes the entire three days of its annual meeting to the discussion of techniques dealing with intramedullary nailing and plate fixation for the treatment of long-bone fractures. This past year's OTA meeting in Toronto featured talks on intracellular Staphylococcus aureus as a proposed mechanism for the indolence of osteomyelitis, growth factor expression in atrophic nonunions, infrared spectroscopy in the diagnosis of acute compartment syndrome, fracture surgery in osteoporotic patients, posttraumatic stress disorder after orthopaedic trauma, EMTALA (Emergency Medical Treatment and Active Labor Act) regulations, and many other topics. It was hardly the narrow-minded technical forum Dr. Sarmiento describes.

I suppose it boils down to whether you see the glass as half empty or half full. It is clear that medical progress leads to better care of patients. It is also clear that increased medical knowledge leads to greater subspecialization and makes it difficult for doctors to stay abreast of the literature. For my part, I am happy to see medical knowledge advance, even if it means that I cannot keep up with my reading as much as I would like. For my patients' sake, I am glad that the inexorable wave of medical research continues to move forward, even if it irritates some who see the glass as half empty.

A. Sarmiento replies:

I appreciate Dr. Starr's comments on my article on subspecialization in orthopaedics. Since I am conscious of the fact that all of the views that I have expressed will one day be proven wrong, I never expected everybody to agree with them. There are no enduring truths in this field of endeavor, and only time will render a verdict. If Dr. Starr were to read again what I said, he would realize that I am keenly aware of the alleged benefits that subspecialization and the proliferation of journals have wrought. I have simply challenged the concept, which he embraces, that more is better.

Too much subspecialization is harmful to our profession because it weakens the glue that has held it together. One need only create the scenario of a midsize community that, because of its small population, can accommodate only fifteen physicians taking care of musculoskeletal conditions. This number of orthopaedists would be appropriate only if all of them were general orthopaedists and not subspecialists; otherwise, the same community would require orthopaedic subspecialists in every subdiscipline: hand, foot, spine, hip, knee, shoulder, elbow, sports, etc., etc. Under these circumstances, there would not be enough work for all of them, and therefore they would not be able to generate enough money to enjoy a decent income. Is Dr. Starr dreaming of a totally socialized system of health care that salaries all physicians and provides every community with subspecialists in all disciplines?

Excessive subspecialization has already raised its ugly head by creating problems in the education of orthopaedic residents. In increasing numbers, senior residents are finding themselves unsure about their readiness to enter private practice. The structured rotation through so many subspecialty areas is making those rotations too short to satisfy their needs. They now seek additional fellowship training, hoping to find a niche where sufficient work can be found. This is not necessarily the result of widespread subspecialization in educational settings, but may be the result of inappropriate utilization and allocation of responsibilities to the subspecialists. This trend cannot be sustained unless the duration of residency is increased, which in my opinion is not a good option.

Dr. Starr devotes most of his criticism to defending the large number of medical journals now published, and he wishes to see more of them. I wonder if all of the information generated by the 30,000 current medical journals consistently translates into greater and meaningful knowledge and to what extent that knowledge makes us wiser.

A calm and objective dialogue concerning these issues is long overdue.

Copyright 2003 by The Journal of Bone and Joint Surgery, Incorporated